Evaluating patient capacity is a common issue in clinical medical ethics. How do we dow what’s best for patients and respect their autonomy while ensuring they are indeed able to make their own medical decisions.
This situations often occur acutely with little time to deliberate. Prepare in advance by listening to this podcast and determining a course of action.
Have a conversation to evaluate the capacity and understanding.
Understand a patient’s overall wishes with regards to their health and lifestyle.
Use a “sliding scale” approach where complex, high-risk decisions require a higher level of “capacity” as opposed to lower-risk les significant decisions.
Determine if mental status changes are acute or chronic, reversible or irreversible.
Welcome to Curbside Ethics. So happy you tuned in. Please share with your fellow clinicians and leave a rating or comment on iTunes. Visit www.StevenBradleyMD.com to request a personalized ethics consultation from our host.
Transcription
O e one welcome back to curb i fleck some drs keven bradley, i’m an ntelani and cinico manicatis is the goal of this program is to empower the listener to make ethical, equitable decisions that affect the lives of their patience. This episode is going to focus on determining between capacity and competence, the funny the difference between these two terms and how we navigate this. In a clinical scenario, we’ll start with a case study where we have a patient twenty four year old, graduate student that comes into the morency department with a friend, they have pretty significant symptoms for a bacterial man. An getas spinal t have shows increase white count. They got nickel rigidity. Gram stain shows grand positive taxi. The recomendation is made that the patient receive antibiotics as the patient symptoms, progress, the mental set us starts to wax and wane. The patient is in former needs immediate hospitalization and antibiotics, and, although he’s drowsy, he appears to understand a position’s explanation. However, here a peases treatment and says he wants to go home position explains the extreme dangers of going gun treated and the minimal risk of treatment. However, the patient continues to refuse treatment. Question is how do you we proceed in such situation. So when you’re talking about capacity and competence, the standard teaching is that competence is a legal term, is to find or dictated by the court he’ll be for a judge, and the judge renders somebody competent or incompetent to do a number of things, whether they’re, incompetent to sign their own legal paperwork or to own their property, and it typically top that competence is assigned by the court system, whereas capacity is evaluated by clinicians and physicians medical staff, it’s a distinction that we often make, however, one that may not be as significant as we truly think when you boil it down, and it comes as far as it comes to medical ethics, competency and capacity can somewhat be used interchangeably. Whenever clinicians judge a patient lacks the decision making capacity. The practical effects of their unability to make these judgment calls don’t differ too much from if they’ve had a legal determination of incompetence, so the lines kind of get blurred in the healthcare setting, and especially when you have time quin strains where it’s not time to go, receive a court order or have a court appointet legal guardian. The medical setting tends to take a slightly different route. The underlying issue that causes this moral distress in this tension is that we have to decide between two ethical principles were trying to evaluate and respect this patient’s autonomy to make decisions about their own person. But we also want to make sure people have the capacity to understand the ramifications of the decision that they’re making oftentimes when there is doubt about a patient and their capacity positions may intervene and uses one to the ground and implied consent were using a reasonable patient standard. Most patients would want x. Human beings typically have the desire to continue living and to aspects of care that coincide with that desire are typically okay in the absence of capacity as determined by the health care team. However, in a non emergent non life threatening situation, there are legal procedures that you can pursue to actually determine competence and to have the right, guardianship or representative installed for this patient care when it comes down to determining decision of capacity. One of the best tools that we have as clinicians is just simply having a conversation with our patients. You sit down understand more about that patient, where they’re coming from their lived history, their insight into the disease process that they have going on the long term effect of this disease, the risk benefits and alternative of the proposed treatment plan. So we have fancy tools and calculators. You can use like the macaco competency assessment test or the aid to capacity valuation. These are more objective measurements you can use, but for a lot of us pecially that aren’t in the mental health realm. Having that conversation and understanding this is: are these patient goals and what they’re saying congruent with their the decisions are making on their health care? It’s often times that we don’t really see a problem or we don’t grow concerned about a patient capacity until they make a decision. That is contrary to what we, as clingin think, is the correct decision for them to make when it comes to defining their presence or absence of capacity, one star with having a conversation, talk with family members and friends and loved ones, as they are available to determin what this patience goals are, and if this is their current presentation is congruent with those previous goals that they’ve set and and discuss what their family members. It’s important to note that capaton, there’s not just an on off where someone does or does not have capacity to make these decisions, often time just on a spectrum and, for example, capacity can be different from one person to another. So if you have a resident physician who is being consented for leproso ic appendectomy versus your average lay person, who’s being consented for an appendectomy, their levels of understanding their risk benefits and alternatives of the procedure are both very different. Therefore, technically their capacity, their decision making capacity is different as well. So what we do need to have is kind of a gate theory. So if you are above this threshold, you have capacity to make it decision. If you’re below said threshold, then you do not have capacity make that decision, but we do need to realize that there there are levels to capacity as we return to this patient. We started discussing a case with who has very clear by terman. Entitas has what appears to be at all altered mental status and is refusing an intervention of antibiotics to treat this picterin and dat is patient states they want to go home. How do we proceed with evaluating and treating or not treating this patient? A lot of it is you need to again have a conversation, sit down and figure out? Why does this patient not want antibiotics, and if they’re explanation aligns with their overall goes of care, then you know patients are allowed to make bad decisions as a coniton, though you’re trying to evaluate this is patient, have a capacity to make this decision. The conversation will go a long way and help you determine that. Let’s assume that this conversation doesn’t give you any more answers. Is it appropriate to valet as patients? Will we have here a genuine ethical conflict between this personal autonomy in your duty as a position to do a spect for a patient to provide beneficence to impose your own paternalistic values and assume that human beings generally want to continue on living? You have to make an ethical decision. We don’t have time in this setting to go to the courts to determine competence to receive instalment of a legal guardian. These are situations that occur in real time and as positions jeff, we ready to make these very decolte decisions, and some of the patient offers no reason for refusing this treatment. We don’t have enough information to say that this decision is congruous with this patient’s overall goals of of care and his wishes in life. As we choose between beneficent and autonomy, we have to resolve this dilemma in this situation. It would be ethically permissible to treat this patient in situations like these. There is the sliding scale when it comes to make these ethical decisions. The sides cut basically recommends that for a procedure that has high benefits and low risk, you need a lower standard of capacity or procedure, thas higher risk and low benefits. You need a higher standard of capacity so for this patient with a high risk. If they don’t receive the antibiotics, they will likely die or have irreversible brain damage very high risk, but a very high benefit that they receive antibiotics and are better the antibiotics themselves coming with a very low risk. If we’re able to assume ficinio allergies is antibiotic, the risk benefit ratio is so skewed that it would be appropriate to treat this patient. On the contrary, if you had a patient who does not seem to understand all the risk benefits and alternatives of a rhino plasty, for example, pearly cosmetic elective procedure, i and you need a higher burden or higher standard of capacity to be able to proceed. That’s kind of what the slaty scale says. I this is a very big deal. Then you really need to make sure the patient has capacity, especially in the risk benefits. Ratio with howard falls so for this patient with bacterian and getas. The recommendation would be to perceive with treatment. This was a true case. Study is actually listed in the book clinical ethics, a practical approach to ethical decisions in clinical medicine, as it turns out once his patient recovered. It turned out that the patient had a family member who had an allergy to an antibiotic and have a bad outcome and allergic reaction and in their period of alternate status, they were concerned about so they similar happening and that’s. Why that’s why they initially refused the antibiotic when you have issues like this, where you have at attention between ben apason and autonomy, couple questions that you can ask to make sure you’re doing the right thing for the patient number number one. Did you explain the critical situation in a clear, understandable way to do your best to reach that patient to explain? What’s going on the risk, benefits and alternatives? Did you do your best for the to help them understand number two: is it possible that language, barriers, education and level or hearing deficits have hindered your patient from understanding what you discussed are. This is recognizing your own internal, biases or cultural differences. Do you need to enlist the help of someone else or some other modality to thoroughly explain this information to the patient number three? Is it possible that fear pain, lack of trust may be keeping his patient from understanding the risk, benefits and alternatives that are being discussed? If so, you may need to enact to alleviate some of those issues and then proceed. Are there any cultural reasons that you should take it to consideration? Are there any differences in values or beliefs that would lead to this disagreement in number? Five is a patient’s decision of capacity subtly impaired by socratic problems such as depression or psychosis, or by medical problems such as a sepolo athy? If so, is this an acute issue or chronic issue is in amiable to treatment through other options? And do you wait or is is acute so capacity and confidence is something that comes up very frequently in health care. I recently had a patient wood had a curtia procedure and the patient needed to go back to the or that same day, because there is a bleeding conversation. The pace was hypotension y needed to go back. They had good mental status and one of my partners discussed a plan for nests and out tained in form consent. But as looking through the medical record, i saw the patient had a significant amount of dazzla to visit azapah. They had a lot of karamin and the procedure earlier that day and for all patients that receive and as tserin we tell them, don’t make any big decisions for twenty four hours. You know once you go home, you have to be with supervision. You can’t be alone because the effects of a medication are still there so technically, even though, according to the riginal patient standard and this patient that come in or surgery to treat this medical condition, and now they needed a life saving surgery to go back technically, they did not have the capacity to consent. For this follow up procedure for the anassein, i was able to explain the risk and benefits with the patient, who seemed to have a very. We had a very good conversation and they seem to understand and repeat back to me everything we talked about, but to flush things all the way out to become completely a tepic l, a t t as i could be. I called that patient’s medical decision maker as well. They that person was aware of this situation. I asked if this decision to go back to the afray room to receive in a seager again with a line of his patients over all goals and wishes, and they sticked that it was and we proceeded and had a really good album for the case they were tuning in or this week’s episode of herbine ethics really enjoy breaking down some of these ethical issues and sparking conversations to discussions all for the benefit of our patients. Hopefully it’s empowers ye to make better ethical and equitable decisions. Is it directly affects alive to the patient that we to caro? I’m not re ceiving bradley your host thanks for tuning in tun in next week for another episode. If you want to know more about me, if you have any ethical, dundrum’s or consultations, please to be a message on my website. Steven bradley mdme follow me on instagram, more twitter, so freely review on on itunes, leave a rating and helped our showder to grow and reach more people thanks. So much for darning us and we’ll talk to you soon, a